Current through Register Vol. 63, No. 9, September 1, 2024
(1) Identification:
All new admissions to the Department of Corrections will receive a mental
health screening interview as part of the intake process. The mental health
screening will include mental health history, suicide potential, evidence of
psychosis, or other acute mental health emergency.
(2) Training: All employees having direct
inmate contact will receive suicide prevention training.
(a) Suicide warning signs, prevention
strategies, and response procedures will be present in New Employee Orientation
(NEO) and in annual in-service training.
(b) Suicide prevention training curriculum
will be approved by the Administrator of Behavioral Health Services.
(c) Additional training is required of staff
on special housing units where mentally ill or suicidal risk inmates are
concentrated.
(3)
Referral: Inmates with significant potential for self harm or who are
displaying suicide warning signs should be referred to Behavioral Health
Services for evaluation.
(4)
Assessment: Any Department staff, upon concluding that sufficient suicide
warning signs are present to merit concern, should immediately notify a
registered nurse or mental health provider. A mental health provider or
registered nurse in consultation with a mental health provider will determine
if suicide risk is present.
(a) When an
inmate is placed on suicide watch or suicide close observation, the inmate
should be reassessed by a registered nurse every four hours and by a mental
health provider within 24 hours, in person or by phone, and once every 24-hour
period thereafter.
(b) At those
facilities without 24-hour nursing coverage, a suicide assessment will be
completed every four hours when nursing staff are on duty, as well as at the
end of the last shift and the beginning of the next shift. During the interim,
specific written instructions shall be given to the officer-in-charge regarding
what actions should be taken if the inmate's mental status appears to
deteriorate, or if any acts of self-destruction are carried out.
(c) All suicide assessment, reassessments,
inmate responses, as well as any written instructions which are given to the
officer-in-charge, will be documented in the inmate's Health Services
file.
(5) Monitoring -
Suicide Watch (high risk): The officer-in-charge shall be responsible for
placing an inmate on suicide watch based on the instruction from a mental
health provider or registered nurse in consultation with a mental health
provider. The officer-in-charge may initiate a suicide watch until a registered
nurse or mental health provider arrives.
(a)
An inmate on suicide watch shall be under continuous and unobstructed
one-to-one observation at all times.
(b) When an inmate is placed on suicide
watch, the officer-in-charge shall remove any items that pose a threat to
self-harm from the inmate's living area based on the instruction from a mental
health provider or a registered nurse in consultation with a mental health
provider.
(c) Any inmate placed on
suicide watch will be continued in this status until a mental health provider,
or a registered nurse in consultation with a mental health provider, determines
that the suicide watch is no longer necessary, and has notified the
officer-in-charge. The officer-in-charge will then order the suicide watch
discontinued and property will be returned as instructed.
(d) If the mental health provider decides to
maintain an inmate on suicide watch past 48 hours, the officer-in-charge will
be notified and arrangements will be made for the transportation of the inmate
to the nearest Mental Health Infirmary. It is the responsibility of the mental
health provider to communicate to the Mental Health Infirmary receiving staff
of the impending admission.
(6) Monitoring -- Suicide Close Observation
(moderate risk): The officer-in-charge shall be responsible for placing an
inmate on suicide close observation based on the instruction of a mental health
provider or a registered nurse in consultation with a mental health provider.
The officer-in-charge may initiate suicide close observation until a registered
nurse or mental health provider arrives.
(a)
Suicide close observation requires unobstructed one-to-one observation of the
inmate at staggered intervals, not to exceed 15 minutes (e.g., 9:15, 9:25,
9:34, 9:49, 10:00).
(b) When an
inmate is placed on suicide close observation, the officer-in-charge shall
remove items that pose a threat to self-harm from the inmate's living area
based on the instruction from a mental health provider or a registered nurse in
consultation with a mental health provider.
(c) Any inmate placed on close observation
will be continued in this status until a mental health provider, or a
registered nurse in consultation with a mental health provider, determines that
the suicide close observation is no longer necessary and has notified the
officer-in-charge. The officer-in-charge will then order the suicide close
observation discontinued and property will be returned according to
instruction.
(7)
Housing: Inmates on suicide watch or suicide close observation may be housed in
a segregation cell or special housing, or other cell modified and identified
for use in suicide prevention if there is a visual and unobstructed view of the
inmate so that he or she can be observed one-to-one on a continuous or
staggered interval basis as required and property can be restricted as
instructed.
(a) A mental health provider
should be consulted as to the most appropriate housing. Upon determination and
instruction by a mental health provider or a registered nurse in consultation
with a mental health provider that an inmate cannot be safely maintained at a
facility while on suicide watch or suicide close observation (in particular,
those facilities without 24-hour nursing coverage), arrangements will be made
to transfer the inmate to an appropriate facility for observation and
intervention.
(b) The mental health
provider or registered nurse in consultation with a mental health provider will
communicate the details of the case to a mental health provider and registered
nurse at the receiving facility before the inmate arrives at the receiving
facility.
(8)
Communication: Throughout the process of suicide risk assessment and
intervention, Department staff and mental health providers will work closely
together to ensure adequate and effective communication.
(9) Intervention: If a staff member discovers
a suicide in progress, the following steps will be followed using universal
blood and body fluid precautions:
(a) Call
for assistance.
(b) If it is a
hanging, the staff member shall cut the inmate down immediately.
(c) Emergency first aid procedures should be
followed in the event of any self-destructive behavior and should be continued
until Medical Services staff arrive and give further instructions.
(d) First aid procedures will be continued
until relieved by Medical Services staff regardless of belief that the inmate
is no longer alive.
(10)
Notification and Reporting: The officer-in-charge will be responsible for
initiating the facility's notification process of any attempted suicide. The
notification will include the local Behavioral Health Services Manager or
designee and the on-call prescriber for that facility where the attempted
suicide took place. In the event of a completed suicide, the notification will
include the local Behavioral Health Services Manager or designee and the
Behavioral Health Services Administrator or designee.
(11) The Department of Corrections rules on
Death (Inmate) (OAR 291-027) and Emergency Preparedness (OAR 291-053) will be
followed in the event of a completed suicide.
Stat. Auth.: ORS
179.040,
423.020,
423.030 &
423.075
Stats. Implemented: ORS
179.040,
423.020,
423.030 &
423.075
